Concern about nurse wellbeing and retention prompted one trust to outsource its clinical supervision to offer a safe place for reflective practice. This article explains more
Abstract
Providing clinical supervision can be challenging in terms of releasing staff and providing nurses with a safe space and time to participate. Concern about staff wellbeing and retention rates prompted one trust to explore an externally devised and delivered clinical supervision programme after previous attempts at providing a sustained model internally had been unsuccessful. Clinical supervision was outsourced to NHS Elect, which supported the trust to use quality-improvement methods to codesign a programme with nursing staff. Early results of this online clinical supervision model are encouraging.
Citation: Thompson D et al (2023) Rewriting clinical supervision using a partnership approach. Nursing Times [online]; 119: 12.
Authors: Deborah Thompson is director, Mandy Rumley-Buss is deputy director; both at NHS Elect. David Thorpe was deputy chief nurse, West Hertfordshire Teaching Hospitals NHS Trust, and is now director of nursing, Bury Care Organisation, Northern Care Alliance NHS Foundation Trust.
- This article has been double-blind peer reviewed
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Introduction
Clinical supervision (CS) is a formal process of professional support and learning. Effective CS should provide a space for nurses to evaluate, reflect on and develop their clinical practice, support professionalism, enhance skills and knowledge, and help mitigate stress and the risk of burnout (Iosom et al, 2021; King et al, 2020). CS has been around since the 1990s (Butterworth, 2022), but increased stress and burnout due to excessive demands on nurse capacity and response since the Covid-19 pandemic has brought its importance to the fore (Van Dam et al, 2023; Galanis et al, 2021).
Despite CS being well established, it has been under-researched, although there is some evidence that suggests it can be effective in supporting person-centred practice (Edgar et al, 2023). Various models of CS exist; for instance, one-to-one supervision by an expert professional in a supervisee’s own speciality can be popular and effective, while group CS can bring lone workers together and reduce work stress (Rothwell et al, 2019). King et al (2020) reviewed the effectiveness of peer-group CS and found it had been used with some success, but cautioned that supervisors need to be skilled in managing group dynamics. The Royal College of Nursing (RCN) (2022) voiced concerns about CS sometimes being delivered to registered nurses by other professions (for example, psychologists) and about the erosion of one-to-one supervision.
King et al (2020) looked at the factors contributing to effective CS. Twelve major themes emerged, revealing the components of an ‘ideal’ CS process. Among them was that the supervisee should not encounter any surprises from a clinical supervisor and that feedback should be ongoing as and when any issues arise. King et al (2020) also reported that student nurses in the study wanted a CS approach that focused on their strengths and ways to build on them.
Butterworth (2022) stressed the key role of the supervisor in CS and stated that it should not be undertaken without adequate preparation, warning that “becoming a supervisor will pose a challenge for most”.
Revisiting clinical supervision
Even before the Covid-19 pandemic, West Hertfordshire Teaching Hospitals NHS Trust was concerned about the wellbeing, morale and retention of its 1,800 registered nurses. Following the pandemic, the trust decided to focus, not just on professional development, but also on personal support and self-development. The trust’s priorities at the end of 2020 were to:
- Support nurses’ health and wellbeing;
- Give them a safe space to reflect on, and work through, any issues;
- Promote a culture of development.
The trust had previously tried to implement CS for nurses but had limited success. Nurses had never fully engaged with CS and it was not embedded in the organisation. A survey of the trust’s nurses had found the existing model of CS lacking, as staff felt the organisation viewed it as a way to manage performance rather than to support wellbeing.
Problems in providing a sustained model of CS internally and the need to overcome a pervasive culture of apathy and cynicism towards CS led the deputy chief nurse to explore the option of outsourcing CS provision. As this was new and there seemed to be no external organisation offering CS for nurses, the trust approached NHS Elect. As a national membership organisation running several successful national improvement networks, NHS Elect offered the relevant skills and expertise, and was already working with the trust.
“The new clinical supervision model focused on health, wellbeing and professional development. It was owned by staff and they could choose whether or not to participate”
Developing the model
NHS Elect agreed to codesign a CS programme with the trust’s nurses using a quality-improvement (QI) approach, and to provide the CS service, as long as it could use the same model for improvement approach used for its other QI programmes.
Work began in 2021, with a project team of representatives from both organisations. The aims of the programme were agreed and a driver diagram created with input from senior nurses to translate these aims into the drivers we had to influence to achieve our goal. Improvement methodology was used; for example, a test of change plan, do, study, act (PDSA) cycle was employed to test the proposed approach and refine it as needed.
Initially, a demand-and-capacity analysis was done to understand the resources needed to deliver CS to nurses in the trust. The trust then carried out an anonymised survey of all nurses’ views on the existing model of CS delivered internally. Although this elicited only 100 responses (<6% response rate), it provided valuable insights into how the model could be improved. Respondents felt they were not given enough time for CS and that the trust did not offer a safe space to discuss issues openly and honestly. Nurses who experienced anxiety or mental ill health, or had a perceived lack of skills, felt vulnerable sharing this with a colleague in the same organisation and were concerned it might become a performance issue.
This validated the trust’s decision to use an external organisation to overcome a culture of cynicism that had grown over time. The new model codesigned by the trust’s nurses and NHS Elect focused on health, wellbeing and professional development. The model was owned by staff and they could choose whether or not to participate.
One-to-one supervision was provided for ward managers, clinical nurse specialists and heads of nursing (band 7s and above), with group supervision for band 5s and band 6s, as there was already a successful preceptorship model in place using group supervision for band 5s. All sessions were delivered online – initially, this was due to Covid-19 restrictions but the success of this format led to it being retained. Supervision for both groups was scheduled every two months.
“We anticipated that psychological distress would be a main concern, but the following emerged as primary themes: professional practice, career development, leadership and quality improvement”
Recruiting supervisors
Nurses external to the trust were recruited as supervisors. These initially comprised six nurses with NHS Elect, followed by the recruitment of associates recommended to the team who were employed and paid to provide supervision. As supervision was online, the geographical location of the supervisors was not a constraint.
Nurse supervisors had to be skilled and experienced across a range of healthcare settings so that they could understand the organisational structures in which nurses were working and the work challenges they faced. All were given training and a supervisor’s handbook. As well as bringing with them a wealth of knowledge and experience, supervisors offered an unbiased and non-judgmental perspective from working outside the trust. The fact that they had no prior knowledge of the nurses they were supervising ensured an environment of anonymity, so nurses felt safe to be open about difficult or contentious issues, without fear of reprisal.
Identifying themes
This model of supervision provided a safe and empowering space for nurses to share ideas, discuss any issues and come up with solutions to problems. Details of individual sessions remained confidential, but NHS Elect devised a coding system allowing supervisors to categorise the types of discussions taking place in both the one-to-one and group sessions. From this, ‘hot topics’ were identified and organised into themes. These contained a few surprises for the trust.
We anticipated that psychological distress would be a primary concern, but the following emerged as main themes:
- Professional practice;
- Career development;
- Leadership;
- QI.
Accumulating this knowledge allowed us to understand what issues were most important to our nurses and find ways to address them.
Winning hearts and minds
The programme was backed up by an information campaign to encourage staff to attend sessions and overcome a culture of apathy about CS. This included a website, information leaflets and a poster campaign. The trust’s deputy chief nurse gave presentations to explain the new approach.
The project team produced podcasts and webinars on the hot topics identified from the one-to-one supervisory sessions; these were hosted on the website and used for the group supervision to encourage junior nurses to talk about the issues. Every eight weeks, the group sessions focused on a new topic. The website, which was up and running within six months, also features information on what CS is and is not, feedback on CS by participating nurses and other information of interest.
Encouraging participation
Everyone eligible for CS was invited via email every 8-12 weeks on an ongoing basis. A dashboard of measures created to track the project’s progress included how many nurses attended supervision from each band and division.
Ward managers arranged cover on the wards to maintain staff–patient ratios when nurses signed up for sessions. Regular group sessions gave every band 5 and band 6 nurse the chance to attend and they could also choose whether to attend in work time or their own time, which they could claim back. Heads of nursing, matrons and ward managers could be released for an hour every two months for one-to-one sessions, without adversely affecting direct clinical care.
Emails were sent out to unresponsive staff encouraging them to participate, but the final choice was theirs. Sharing monthly attendance reports across divisions demonstrated progress for each, and led to some healthy competition across the organisation in terms of encouraging nurses to attend.
Measuring success
It is early days in terms of assessing the success of this new CS programme, but initial indications are encouraging.
Among senior nursing staff, 66% (n=91) of band 8s and 49% of band 7s (n=151) have taken up the offer of one-to-one supervision. Between January 2021 and November 2022, 1,020 one-to-one sessions had been delivered to band 7 and band 8 nurses (Fig 1), and 319 group sessions had been delivered to band 5 and band 6 nurses.
Participants were asked to rate their experience of the CS sessions from 1 to 10 (with 10 being most positive). The feedback gathered was overwhelmingly positive. Responses from 21 senior nurses showed nearly all (n=18) rated the one-to-one sessions at 8 to 10, with nearly half (n=10) awarding a top rating of 10. Similarly, feedback on the group supervision from 24 junior nurses showed that more than half (n=15) rated it at 8 to 10, and a quarter (n=6) awarded a top rating of 10 (Fig 2). Some of the positive comments received via further surveys and one-to one discussions with heads of nursing are given in Box 1.
Box 1. How the clinical supervision programme was received
Examples of feedback from supervisees
“Thank you for helping me raise my awareness of the challenges I face and how I can develop my abilities to support and impact on my department.”
“This is so helpful, and I feel validated and valued.”
“I came away from the session with a spring in my step.”
“It was lovely to see a smiling face and be listened to.”
Commentary from the chief nurse and director of infection prevention control
“We cannot underestimate how, in the challenging world of healthcare, [clinical supervision] assists our health and wellbeing, while supporting development and empowerment. It takes remarkable people to be healthcare professionals who do amazing things every day, and clinical supervision is key to helping us be the best we can be in our professions as nurses, midwives and [allied health professionals].”
As a result of CS, it now appears that the trust has a more engaged workforce and there has been a shift in the organisation towards staff engagement, with senior nurses taking their discussions back into the workplace and using them to initiate projects – one example of this is QIs in older people’s care. The trust is also seeing nurses raise issues they might have been reluctant to raise before, such as advanced clinical practitioners (ACPs) highlighting the lack of a standardised career development framework for all ACPs. Published monthly figures on CS and topics arising also increased awareness among senior nurses.
Learning points
Use of improvement methodology to co-design the CS programme underpinned its success. This was backed by robust systems and data capture, which are also being used to evaluate the project. Monthly project meetings and regular highlights reports helped to maintain momentum and focus, while showing staff via the project team and the CS webpage how the programme was both progressing and being refined.
The codesign approach was important in engaging senior nurses and overcoming a pervasive culture of apathy and cynicism about CS in the trust. Good organisational support also helped to ensure CS was embraced by the nursing workforce and the new model was embedded in practice.
Use of external supervisors means nurses now have protected time to talk to a senior nurse outside of the organisation, who can understand and support them to develop professionally. Supervisors’ wide range of experience means they understand both the internal workings of hospital divisions and the wider healthcare system. This enables them to:
- Connect what is happening in the trust to national policy initiatives and national organisations, such as NHS England;
- Link supervisees to national networks and resources that can help them to expand their knowledge and practice.
Challenges
The external model of supervision is working well, but there are still some challenges. There is no ‘one-size-fits-all’ approach and the trust can still struggle to get all staff to participate. In particular, ward pressures can sometimes make it difficult to ensure adequate cover for nurses to attend sessions. The trust also recognises that supervision is only one component of the support that nurses need.
Next steps
As healthcare becomes ever more complex and demanding, effective CS supports nurses to develop and continuously review and improve themselves, and allows organisations to confront and resolve difficult issues at source.
Many NHS organisations pay ‘lip service’ to CS and it is not always properly anonymised or systematised. We believe the approach implemented in our trust could be adapted and spread more widely across the NHS to ensure effective CS. Box 2 summarises the key success factors and learning points from the West Hertfordshire experience.
Box 2. Learning points for an externally delivered clinical supervision programme
- Communicate and codesign with nurses from the outset
- Use quality improvement methodologies and tests of change to develop and refine your approach
- Ensure executive team support and effective promotion throughout, including at the senior leaders’ forum
- Create a project team of executives from both organisations and meet monthly to codesign, review progress and agree next steps and tests of change cycles
- Use virtual delivery and external supervisors as a way to provide a safe space for supervision
- Create protected time for staff to participate in supervision
- Ensure confidentiality for supervisees, while identifying recurrent themes from supervisory sessions to help shape your strategy and education plans
- Consider a phased approach as this can help build staff trust
The trust has extended its contract with NHS Elect to continue one-to-one sessions for band 7 and band 8 nurses. Band 5 and band 6 nurses now have access to one-to-one supervision via the professional nurse advocate programme, the nationally funded restorative CS programme launched by NHS England in March 2021 (NHS England, 2023). The trust now has several trained professional nurse advocate supervisors, who offer supervision to junior staff as required. As part of this blended model, NHS Elect is also developing and delivering webinars that will be available on the CS website to support all staff, with much of the content aimed at band 5 and band 6 nurses.
Conclusion
QI methodology and a codesign approach was used to deliver an externally devised and delivered programme of CS at West Hertfordshire Teaching Hospitals NHS Trust. Moving forward, this will complement the nationally funded professional nurse advocate programme. Backed by robust systems and data capture, this approach is already showing demonstrable signs of success and could be applied more widely across the NHS to ensure effective CS provision.
Key points
- Clinical supervision helps improve nurses’ skills and knowledge, and reduce stress and burnout
- Effective clinical supervision can be challenging to provide and sustain
- Codesigning a framework with staff using quality-improvement methods is beneficial
- Use of external supervisors creates a safe space for nurses to reflect on their practice
- Creating protected time for supervision is key but remains challenging for ward staff
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